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HomeMy WebLinkAbout06-12-12 (2)J 1505610105 . REV-1500 EX (oz-ii) (FI) 1 ~1 t.~1JJ OFFICIAL USE ONLY PA Department of Revenue Pennsylvania Bureau of Individual Taxes ~ E .,. Po Box Zso6o1 INHERITANCE TAX RETURN County Code Year ~ File Number ~ RESIDENT DECEDENT H i PA ' b 8 6 ~t- I '' / ~~ arr urg, 1 712 s -0 01 _l ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 214-46-6112 01 /19/2011 05/25/1915 Decedent's Last Name Suffix Decedent's First Name MI Scoropanos Demetra K (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILE D IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) t'3D 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone NurrtbeY Steve C. Nicholas, Esq. (717) 540-7746 First Line of Address 2215 Forest Hills Drive Second Line of Address Suite 37 City or Post Office Harrisburg Correspondent's a-mail address: © rv REGISTER OF SE ONLY ~-- ~ r~~ ~ ::.? ~ ~ ~ r~ ©~ - State ZIP Code DATE FILED tt~ PA 17112 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correc nd co plete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNAT P SON RE IBLE F FI G RETURN D TE ~~~/ L 477 E. Elmwood Avenue, Mechanicsburg, PA 17055-4277 SIGNATU OF~r~pp$rcl; OT~iIXf~ TtIAN RE$R~ENTATIVE ADDKESS t I 2215 Forest Hills Drive, Suite 37, Harrisburg, PA 17112-1099 PLEASE USE ORIGINAL FORM ONLY L 1505610105 Side 1 1505610105 `! ~~/ ~ 1505610205 REV-1500 EX (FI) Decedent's Social Security Number Decedent's Name: SCOfOpanOS, Demetra K. 214-46-6112 RECAPITULATION 1. Real Estate (Schedule A) ........................................... .. 1. 2. Stocks and Bonds (Schedule B) ..................................... .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. 4. Mortgages and Notes Receivable (Schedule D) ......................... .. 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 6,637.96 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 8. ( 9 ) .......................... Total Gross Assets total Lines 1 throu h 7 8. ... 6,637.96 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 4,049.66 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 232,565.13 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 236,614.79 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. -229,976.83 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 0.00 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 _ 1 5. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 19. TAX DUE ...................................................... ... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 File Number Decedent's Complete Address: Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount Total Credits (A + g) (2) 0.00 3. Interest (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income ............................................ ^ c. retain a reversionary interest .............................................................................................................................. ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in [72 P.S. §9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-i5o8 EX+ (ii-io) -j~i Pennsylvania SCHEDULE E '.~J DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Scoropanos, Demetra K. a/k/a Demetra L. Scoropanos a/k/a Demetra Scoropanos 21 11 1235 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) 7 i'1 pennsylvania •~ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Scoropanos, Demetra K. a/k/a Demetra L. Scoropanos a/k/a Demetra Scoropanos 21 11 1235 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Funeral -Neill Funeral Home, Inc. 507.07 z. Funeral - St. John's Episcopal Church 200.00 s. Gratuity for Priest 50.00 a. Funeral luncheon -Nick's Airport Inn 1,218.26 s. Burial dress -George's Cleaners 19.03 e. 40 Day Service -Flowers, koliva and coffee hour 210.00 ~. Memorial reception at Claremont Facility 157.02 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City _._._ _....... ....._.. State _._. ZIP Year(s) Commission Paid: 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City --_ State _..._._ ZIP _._- Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 6. Tax Return Preparer Fees: ~• Short Certificates - Register of Wills a. Inheritance Tax Returns - Register of Wills s. Inventory - Register of Wills ~ o. Adveritising -Cumberland Law Journal and The Sentinel ~ ~ . Postage, copies, notary -Nicholas Law Offices, PC 1,250.00 80.50 12.00 15.00 15.00 285.78 30.00 TOTAL (Also enter on Line 9, Recapitulation) $ 4,049.66 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania SCHEDULE I DEPARTMENT OE REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Scoropanos, Demetra K. a/k/a Demetra L. Scoropanos a/k/a Demetra Scoropanos 21 11 1235 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) j i~ pennsylvania SCHEDULE ~ DEPARTMENT DE REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT - _. -- - - ESTATE OF: FILE NUMBER: Scoropanos, Demetra K. a/k/a Demetra L. Scoropanos a/k/a Demetra Scoropanos 21 11 1235 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• SEE EXHIBIT A ATTACHED HERETO ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. Scoropanos Demetra Schedule J scn/est SCHEDULE J BENEFICIARIES Estate of Demetra K. Scoropanos a/k/a Demetra L. Scoropanos File Number: 21-11-1235 a/k/a Demetra Scoropanos A. Taxable Distributions Amount or No. Name /Address of Beneficiary Relationship Share of Estate 1. Christopher Brown Grandson $500 1827 15`h Street, #2 San Francisco, CA 94103 2. Andrea Butler Granddaughter $500 21112 Kaul Lane Germantown, MD 20876 3. Ryan Ellis Grandson $500 1631 Ivy Spring Drive Smyrna, GA 30080 4. Julie Goodall Granddaughter $500 8625 Delta Dawn Lane Fair Oaks Ranch, TX 78015 5. Stefan Kanelakis Grandson $500 477 E. Elmwood Avenue Mechanicsburg, PA 17055 6. Demetri Kanelakis Grandson $500 7 Smiley Drive Mechanicsburg, PA 17055 7. Kimon Kanelakis Grandson $500 316 Todd Place NE Washington, DC 20002 8. Alexander Scoropanos Granddaughter $500 + 1/16 rest, 213 W. King Street residue & remainder Malvern, PA 19355 9. Andonia Scoropanos Granddaughter $500 + 1/16 rest, 170 Irvington Avenue, Apt. 106 residue & remainder South Orange, NJ 07079 EXHIBIT "A" Page 1 of 2 10. Elias Scoropanos Grandson $500 + 1/16 rest 294 Wiley Place residue & remainder Wyckoff, NJ 07481 11. Stephanie Scott Granddaughter $500 245 Pleasant Grove Road Long Valley, NJ 07853 12. Dimitra Stambaugh Granddaughter $500 + 1/16 rest 416 Hidden Valley Road residue & remainder New Cumberland, PA 17070 13. Alexandra Ellis Daughter '/4 rest, residue & 2741 Mackinnon Ranch Road remainder Cardiff by the Sea, CA 92007 14. Christine Kanelakis Daughter '/a rest, residue & 477 E. Elmwood Avenue remainder Mechanicsburg, PA 17055 15. Johanna Pritsios Daughter '/4 rest, residue & 12832 Clarksburg Square Road, #30 remainder Clarksburg, MD 20871 B. Nontaxable Distributions Amount or No. Name /Address of Beneficiary Share of Estate EXHIBIT "A" Page 2 of 2 WILL OF DEMETRA K. SCOROPANOS AKA DEMETRA L. SCOROPANOS OR DEMETRA SCOROPANOS I, Demetra K. Scoropanos, aka Demetra L. Scoropanos or Demetra Scoropanos of Cumberland County, Mechanicsburg, Pennsylvania, declare this to be my last Will and hereby revoke all prior Wills and Codicils. 1. I direct that all my just debts, funeral expenses, graver~larker and administrative expenses sha!! he paid from my residuary estate as soon as practicable after my death. 2. I direct that all inheritance, estate, transfer, succession and death taxes of any kind whatsoever which may be payable by reason of my death shall be paid out of my '~ residuary estate. 3. I direct that my entire estate be distributed as follows: A. I leave $500.00 to each of my grandchildren. '~ B. The remainder of my estate should be divided into equal shares to my children, Johanna Pritsios, Alexandra Ellis, Thomas Scoropanos and Christine Kanelakis. C. If any of my children should predecease me, their share shall lapse and go to their children. D. !f there is not s~!ff!elent !??Onpy in my ec#ater I IeavP_. it to the discretion of my Executrixes how much to leave. 4. I appoint Johanna Pritsios and Chirstine Kanelakis, jointly, as Executrixes of this my last Will. 5. The Executrixes of this Will shall have the power to distribute my estate in kind or in cash, or partly in either. LAW OFFICES OF STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 6. I direct that no Executrix acting under this Will shall be required to enter bond in any jurisdiction. y~L ` ~ ~ ~~ Ca .rYI ~- ~L~L~o ~~ ~6 The preceding instrument consisting of this and one other page was on the day and date hereof signed, published and declared by Demetra K. Scoropanos, aka Demetra L. Scoropanos or Demetra Scoropanos as and for her last Will in the presence of us, who at her request, in her presence and in the presence of each other have subscribed our names as witnesses hereto. LAW OFFICES OF TEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 /,,12 ~' ITNESS ~~ ~J4!lTNESS IN WITNESS WHER OF, hav hereunto set my hand this day of (_~-~~ , 2005. Demetra K. Scoropanos ~ Aka Demetra L. Scoropano~'~-c-- Or Demetra Scoropanos LAW OFFICES OF TEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 ACKNOWLEDGMENT State of Pennsylvania County of Cumberland ss I, Demetra K. Scoropanos, aka Demetra L. Scoropanos or Demetra Scoropanos, the Testatrix, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last Will; that I signed it willingly and as my free and voluntary act for the purposes therein expressed. Demetra K. Scoropanos Aka Demetra L. Scoropanos Or Demetra Scoropanos LAW OFFICES OF STEPHEN J. NOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 Sworn to or affirmed and acknowledged before me by Demetra K. Scoropanos, aka Demetra L. Scoro Demetra Scoropanos the Testatrix, this ~ day of ~~~~;'/ , 2005. ._ ^.a±a .. ~ ~A Si7EPHEN J. h10pQ, NQfAP' t ~t180R0, pyp CO.. PP r ,.• `~Y`°""""'°"°`"~'~"'°~"~~ Not~r'ji, blic/Attorn State of Pennsylvania County of Cumberland AFFIDAVIT ss We,~U.SGtn ~ ~~-..SAE'S and ~-JSu u, ~~ yeY~ ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law., do depose and say that we were present and saw the Testatrix sign and execute the instrument as her last Will; that the Testatrix signed willingly and executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Will as a witness; and that to the best of our know edge the Testatrix was at that time 18 or more years of age, of son mind and under no constraint or ndue influence. r < ~ ~. Sworn to or ~irm ~ subscribed to before me by witnesses, this ~~ day of (~'/.`~ ~-C~ ~'` , 2005. worua~s~ --~ ,. v /: szta~ ~. Hooo. Noma : ~,~ ~~«~_¢rNc~tary Public/Attorn crowue~~oa, ova severe s, aoas { ~~~ Q M8T Bank 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services Phone 888-502-4349 F ax (302) 934-2955 February 13, 2012 Nicholas Law Offices, PC Northwood Office Center 2215 Forest Hills Drive, Suite 37 Harrisburg, PA 17112-1099 Re: Estate of Demetra L Scoropanos Social Se^l.'u~it~r': ~1~-46-b112 Date of Death: January 19, 2011 Dear Sir or Madam: Per your inquiry on February 3,2012, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: ] . Type of Account Account Number Ownership (Names of) Opening Date Balance on Date of Death Checking Account 858862 Demetra L Scoropanos 02/19/1988 $3, 686.08 Accrued Interest Total $ .00 _._ $3, 686.08 For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, please call the Trindle Road @ 717-737-2308 We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any accounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sincerely, oil ,~ ~,~ Tammy Spencer Adjustment Services - ,..r ,,, -o-..,~.~z ~ ,vim ~-V.-:--~-;~.w_ --_.. CLAREMONT NURSING & REHABILITATION CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013-8820 60-430/373 2/29/2012 PAY TO THE The Estate ofDemetro Scoropanos ~ **2,703.42 ORDER OF Two Thousand Seven Hundred Three and 42/100************************************************** DOLLARS The Estate of Demetro Scoropanos VOID AFTER 90 DAYS C/O Nicholas Law Offices, PC SP ~ F Northwood Office Ctr. _ --_ _-_.~`~'~`____.~_. Qos 2215 Forrest Hills Dr, Ste 37 ~ n ~~~--~~_~~?~ -_. _.- FG MEMO Harrisburg, PA 17112-1099 -~` "~ ``° SAO S~ replace close out chk #41907 to close PCA ~,,: it°04 278611' x:03 ~304306l: 1 L~~~ 2848511' CLAREMONT NURSING & REHABILITATION CENTER The Estate of Demetro Scoropanos Date Type Reference 2/29/2012 Bill Demetro Socropanos F~~SINI 42786 2/29/2012 Balance Due Discount Payment 2,703.42 2,703.42 Check Amount 2,703.42 2,703.42 Original Amt. 2,703.42 Checking replace close out chk #41907 to close PCA ca~~r~~Q B1ueCross B1ueShield CareFrst BlueCross BlueShield is the business name of GrOUp Hospitalization and Medical Services, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®' Registered trademark of CareFirst of Maryland, Inc. DEMETRA SCOROPANOS C/0 CHRISTINE KANELAKIS 477 E ELMWOOD AVE MECHANICSBURG, PA 17055 ;oo- -~ _ Check Number _ (~ lI'S ~~ ~° `'6tRtreet. N.E. .70355207 U 0 0 810 017 Was h: nymn. D G, 20065 B1ueCrossBlneShield ®Regstere6tratlcmarkofthe0lueCro55antl81ueShieldASSOCiat;on. ®' RC9:Stgrctl-trademark of CareFirSL of Maryta nd. Ine. Ca reFi rst BlueC toss 0l ueSh:cltl sthehusiness na me of GrDUp Hospttaliz~teain and MCdICaI MO DAY YR 64-78 $CNIGeS, rBC.amf isanintlepentle~rt Licensee of the 0lueCross andBlue Snield lssociation. 6'11 03 07 12 PAY TO THE ORDER OF: DEMETRA SCOROPANOS _ ID NUMBER 900393549 AlIAOUNT $ ~*~*~~**248.46~ EXACTLY T.WO HUNDRED FORTY-EIGHT AND 46/i0Q DOiLARS~ ~~ ~,~/~~ S U~r ~* NOT VALID 'OVER $30fl ** ~ ti~ . Not Yalid'After 6 MDaths 11' 70 3 5 5 20 711• t:06 L L00 790: 8800 S L L 7041I• ~• Pennsylvania ~• . DEPARTMENT OF PUBLIC WELFARE March 19, 2012 NICHOLAS LAW OFFICES STEVE C NICHOLAS ESQUIRE 2215 FOREST HILLS DR STE 37 HARRISBURG PA 17112-1099 Re: Demetra Scoropanis CIS# : 660197449 SSN: ###-##-6112 Date of Death: 01/19/2011 Dear Attorney Nicholas: Please be advised that the Department of Public Welfare maintains a claim in the amount of $232,565.13 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $31,074.09, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $201,491.04, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, rJ , Elvetta E. Knox Claims Investigation Agent 717-772-6613 717-772-6553 FAX Enclosure Bureau of Program Integrity ~ Division of Third Party Liability ~ Recovery Section PO Box 8486 i Harrisburg, Pennsylvania 17105-8486 ~• Pennsylvania ~~ . DEPARTMENT OF PUBLIC WELFARE MEMO TO: Attorney Nicholas FROM: Elvetta E. Knox Claims Investigation Agent Division of TPL, Recovery Section 717-772-6613 DATE: March 19, 2012 SUBJECT: Information Needed RE: Demetra Scoropanis CIS#: 660197449 Incident Date: 01/19/2011 Please submit a full and final itemized accounting of any and all assets in the estate with supporting documentation; copy of original deed(s), inheritance taxes; funeral expenses with the pre-paid burial papel-vvork, original bank signature card with date of joint ownership, bank statement at the time of death, Nursing Home personal care accoLU~t statement, insurance papers to confirni beneficiary, stocks bonds, vehicles, etc. The Department needs to know where funds came from and where any remaining balance if any went for the tiuieral/burial with supporting documentation. This case will remain open for recovery until it has been satisfied via monetarily and/or through documentation. Bureau of Program Integrity ~ Division of Third Party Liability ~ Recovery Section PO Box 8486 ~ Harrisburg, Pennsylvania 17105-8486 ~~,~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 February 9, 2012 STATEMENT OF CLAIM SUMMARY NAME Estate of SCOROPANIS, DEMETRA ID 660 197 449 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 -00 LONG TERM CARE 31,074.09 201,469.92 232,544.01 DRUG .00 21.12 21.12 REIMBURSEMENT TO DPW 31,074.09 201,491.04 232,565.13 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS, DEMETRA ID 660 197 449 PINNACLE HLTH SNU SEIDLE MEM HSP 120 S FILBERT ST ECHANICSBURG PA 17055 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 09/01/07 - 09/30/07 04!14/08 27080774020230001 27080774020230001 5,126.93 5,126.93 DIAGNOSIS 1 : 43820 HEMIPLEGIA AFFECTING UNSP DIAGNOSIS 2 : 0 PROC CODE : 000000 10/01/07 - 10!31/07 DIAGNOSIS 1 : 43820 DIAGNOSIS 2 : 0 PROC CODE : 000000 11/01/07 - 11/19/07 DIAGNOSIS 1 : 43820 DIAGNOSIS 2 : 0 PROC CODE : 000000 04/14/08 27080774020260001 HEMIPLEGIA AFFECTING UNSP 27080774020260001 5,220.23 5,220.23 04!14108 27080774020320001 HEMIPLEGIA AFFECTING UNSP 27080774020320001 2,790.53 2,790.53 PROVIDER SUB TOTAL PINNACLE HLTH SNU SEIDLE MEM HSP 13,137.69 13,137.69 03 100002563 0114 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS, DEMETRA ID 660 197 449 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN. USUAL CHARGES AMOUNT APPROVED 11/19/07 - 11/30/07 O6/02/08 510812640202.60001 51081264020260001 2,399.52 2,399.52 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 12/01/07 - 12/31/07 04/28/08 20080954033480001 20080954033480001 6,198.76 5,719.76 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS CIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 01!01/08 - 01/31/08 04/28/08 20080954033490001 20080954033490001 6,198.76 5,708.76 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 02/01/08 - 02/29/08 04/28/08 20080954033500001 20080954033500001 5,798.84 5,308.84 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 03/01/08 - 03/31/08 04/28/08 20080954033510001 20080954033510001 6,198.76 6,154.26 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 04/01/08 - 04!30/08 06/02/08 20081264032240001 20081264032240001 5,998.80 5,954.30 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 05/01/08 - 05/31/08 06/30/08 20081574030170001 20081574030170001 6,198.76 5,708.76 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 06/01/08 - 06/30/08 07/28/08 20081854041090001 20081854041090001 5,998.80 5,508.80 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS, DEMETRA ID 660 197 449 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 07/01/08 - 07/31/08 03/02/09 55090574337810001 55090574337810001 6,198.76 6,216.26 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 08!01/08 - 08/31/08 03/02/09 55090574339920001 55090574339920001 6,198.76 5,770.76 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 09/01/08 - 09/30/08 03/02/09 55090574342310001 55090574342310001 5,998.80 5,568.80 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 10/01/08 - 10/31/08 03/23/09 55090774430760001 55090774430760001 6,198.76 6,216.26 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 11/01/08 - 11/30/08 03/23/09 55090774432840001 55090774432840001 5,998.80 5,568.80 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 12/01/08 - 12!31/08 03/23/09 55090774435050001 55090774435050001 6,198.76 5,770.76 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 01/01/09 - 01/31/09 04/27/09 51091004020310001 51091004020310001 6,198.76 5,733.76 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 02/01/09 - 02/28/09 06/01/09 69091324021970001 69091324021970001 5,598.88 5,573.38 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 311 DEPRESSIVE DISORDER NEC PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS, DEMETRA ID 660 197 449 CUMBERLAND CO COMMRS 1000 CLAREM ONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN 03/01/09 - 03/31/09 04/27/09 20091004028640001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 04/01/09 - 04/30/09 05/25/09 20091274054070001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 05/01/09 - 05/31/09 06/22/09 20091554049670001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 06/01/09 - 0 6/30/09 07/20/09 20091824070210001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 07/01/09 - 07/31/09 11/08/10 55103064583840001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 08/01/09 - 08/31/09 11/08/10 55103064585900001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 09/01/09 - 09/30/09 11/08/10 55103064588020001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 10/01/09 - 10/31/09 11/15/10 55103144580150001 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 ADJUSTED CRN I USUAL CHARGES I AMOUNT APPROVED 20091004028640001 6,198.76 5,733.54 20091274054070001 6,058.80 5,977.08 20091554049670001 6,260.76 5,733.54 20091824070210001 6,058.80 5,531.58 55103064583840001 6,260.76 6,241.66 55103064585900001 6,260.76 5,796.16 55103064588020001 6,058.80 5,592.18 55103144580150001 6,260.76 5,796.16 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS,DEMETRA ID 660 197 449 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 11!01/09 - 11/30/09 11/15/10 55103144582260001 55103144582260001 6,058.80 5,592.18 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 33829 OTHER CHRONIC PAIN PROC CODE : 000000 12/01/09 - 12/31/09 11/15/10 55103144584930001 55103144584930001 6,260.76 6,323.38 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 01/01/10 - 01/31/10 11/29/10 55103274573790001 55103274573790001 6,260.76 6,087.07 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 02/01/10 - 02/28/10 11/29/10 55103274575860001 55103274575860001 5,654.88 5,388.83 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 03/01/10 - 03/31/10 11/29/10 55103274577890001 55103274577890001 6,260.76 6,313.78 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 04/01/10 - 04/30/10 12/13/10 55103424563590001 55103424563590001 6,058.80 5,884.34 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 05/01/10 - 05/31/10 12/13/10 55103424565550001 55103424565550001 6,260.76 5,700.26 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 06/01/10 - 06/30110 12/13/10 55103424567690001 55103424567690001 6,058.80 5,496.28 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS, DEMETRA ID 660 197 449 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 07/01/10 - 07/31/10 01/17/11 55110114145170001 55110114145170001 6,260.76 6,262.43 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO PROC CODE : 000000 08/01/10 - 08/31/10 01/17/11 55110114147180001 55110114147180001 6,260.76 6,262.43 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 _ OTHER PERSISTENT MENTAL DI SORDERS DUE TO - PROC CODE : 000000 09/01/10 - 09/30/10 09/19/11 69112464020010001 69112464020010001 6,058.80 5,722.61 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 2948 OTHER PERSISTENT MENTAL DI SORDERS DUE TO PROC CODE : 000000 10/01/10 - 10!31/10 02/07/11 55110324148480001 55110324148480001 6,260.76 5,761.64 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 3558 MONONEURITIS LEG NOS PROC CODE : 000000 11/01/10 - 11/30/10 02/07/11 55110324150640001 55110324150640001 6,119,40 5,555.68 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 7823 EDEMA PROC CODE : 000000 12/01/10 - 12/31/10 02/07/11 55110324152780001 55110324152780001 6,323.38 5,761.64 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 7823 EDEMA PROC CODE : 000000 01/01/11 - 01/19/11 02/21/11 20110324163270001 20110324163270001 2,608.80 2,010.09 DIAGNOSIS 1 : 4389 UNSPECIFIED LATE EFFECTS DIAGNOSIS 2 : 41090 UNSPEC SITE EPIS OF CARE PROC CODE : 000000 PROVIDER SUB TOTAL CUMBERLAND CO COMMRS 231,766.46 219,406.32 03 100007309 0009 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE February 9, 2012 STATEMENT OF CLAIM NAME SCOROPANIS,DEMETRA ID 660 197 449 PHARMERICA INC #22000 491A BLUE EAGLE AVE ARRISBURG PA 17112 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN 09/12/08 - 09/12/08 10/06/08 25082565622750001 25082565622750001 DIAGNOSIS 1 : 0 NDC CODE : 00472110556 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS USUAL CHARGES AMOUNT APPROVED 11.63 7.12 09/18/08 - 09/18/08 10/13/08 25082625263020001 25082625263020001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZN 500 UNIT/GM DINT - OTHER ANTIBIOTICS 12/08/08 - 12/08/08 01/05/09 25083435459150001 25083435459150001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZN 500 UNIT/GM OINT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL PHARMERICA 27.27 21.12 24 100751181 0032